TRAUMA GINJAL

SUB BAGIAN UROLOGI

BAGIAN/SMF BEDAH
FK UNS/RSUD Dr. MOEWARDI

PENDAHULUAN
10% trauma abdomen trauma traktus
urogenitalis
Trauma urogenitalis trauma ginjal >>>
5% trauma abdomen
Dewasa muda sekitar 74%, usia tua 15%,
dan anak-anak 9%
Sering bersama trauma organ lain
(multiorgan trauma).
AS : trauma ginjal bersama hepar (40%),
lien (5-7%), pankreas (13%), kolon (7%) dan
usus halus / gaster (3%)

ETIOLOGI
Trauma tumpul (Blunt Injury) 80-85%
Mekanisme trauma tumpul ginjal :
1. Trauma langsung pinggang kosta 11 & 12
fraktur melukai ginjal
2. Trauma tumpul bagian depan abdomen
3. Jatuh terduduk dari ketinggian

AAST Renal Injury Grading Scale

Grade* Description of Injury

Contusion or non-expanding subcapsular
1
haematoma
No laceration
2
Non-expanding peri-renal haematoma
Cortical laceration < 1 cm deep without
extravasation
Cortical laceration < 1 cm without urinary
3
extravasation
Laceration: through corticomedullary junction into
4
collecting system
Or
Vasculary: segmental renal artery or vein injury with
contained haematoma, or partial vassel laceration,
or vessel thrombosis

ETIOLOGI
Trauma tembus (penetrating
injury)
1. luka tusuk (stab wound)
2. luka tembak (gun shot)
. 80% luka tembus ginjal
trauma visera intraabdomen
. intervensi operatif

KLASIFIKASI

DIAGNOSIS
1. Riwayat trauma

2. Hematuria (95%)
3. Hematoma di regio flank
4. Fraktur costa bawah
5. Hemodinamik tidak stabil
(hipotensi)

History and Physical Examination

Recommendations
Haemodynamic stability should be decided upon
admission
History should be taken from conscious patient,
witnesses and rescue team personnel with regard to
the time and setting of the incident

GR
B
C

Past renal surgery, and known pre-existing renal

abnormalities (ureteropelvic junction obstruction, large
cysts, lithiasis) should be recorded

A though examination should be made of the thorax,

abdomen, flanks and back for penetrating wounds

Findings on physical examination such as haematuria,

flank pain, flank absasions and ecchymoses, fractured
ribs, abdominal tenderness, distension or mass, could
indicate possible renal involvement

Laboratory Evaluation

Recommendations

GR

Urine from a patient with suspected renal injury

should be inspected grossly and then by dipstick
analysis

Serial haematocrit measurement indicates blood

loss. However, until evaluation is complete. It not be
clean whether it is due to renal trauma and or
associated injuries.

Creatinine measurement could highlight patient who

had impaired renal function prior to injury

PEMERIKSAAN IMEJING GINJAL

Dahulu: IVP skg: CT Scan kontras
Jk fasilitas CT Scan (-) pakai IVP
Indikasi:
1. Trauma tembus regio flank / abdomen
tdk lihat derajat hematuria
2. Trauma tumpul dewasa dg gross
hematuria /mikrohematuria + shock
(sistolik < 90 mmHg)
3. Trauma deselerasi
4. Trauma mayor berhubungan trauma
intra-abdominal & mikrohematuria
5. Trauma abdomen / flank penderita anak
dengan hematuria

Imaging
Recommendation

GR

Blunt trauma patients with macroscopic or microscopic haematurial (at

least 5rbc/hpf) with hypotention (systolic blood preassure <90mmHg)
should undergo radiographic evaluation

Radiographic evaluation is also recommended for all patients with a

history of rapid declaration injury and/or significant associated injuries.

All patients with any degree of haematuria after penetrating abdominal

or thoracic injury require urgent renal imaging

Ultrasonograpy can be informative during the primary evaluation o

polytrauma patients and for the follow-up of recuperating patients,
although more data is required to suggest this modality university

A CT scan with enchancement of intravenous contrast material is the

best imaging study for the diagnosis and staging of renal injuries in
haemodynamically stable patients

Unstable patients who require emergency surgical exploration should

undergo a one-shot IVP with bolus intravenous unjection of 2mL/kg
contrast

Formal IVP/, MRI and radiographic scintigraphy are acceptable secondline alternative for imaging renal trauma when CT is not availabel

Angiography can be used for diagnosis and simultaneous selective

embolisation of bleeding vessels

PENGELOLAAN NON OPERATIF

98% trauma tumpul renal
Penderita hemodinamik stabil & staging (+)
& CT Scan (+)
Trauma tembus luka tembak / tusuk
staging hati-hati dg CT Scan monitor ketat
55% trauma tusuk & 24% trauma luka
tembak nonoperatif
Trauma derajat III & IV monitor ketat
(serial hematokrit & CT Scan)
perdarahan persisten angiografi
embolisasi

Non-operative Management of Renal Injuries

Recommendations

GR

Following grade 1-4 blunt renal trauma, stable patients should

be manage conservatively with bed-rest, prophylactics
antibiotic and continuous of vital signs until haematurial
resolves

Following grade 1-3 stab and low-velocity gunshot wounds,

stable patients, after complete staging, should be selected
expectant management

Indicated for surgical management include

Haemodynamic instability
Exploration for associated injuries
Expanding or pulsatile peri-renal haematoma identified during
laparotomy
Grade 5 injury
Incidental finding of pre-existing renal pathology requiring
surgical therapy
Renal reconstructing should be attempted in cases with
where the primary goal of controlling haemorrhage is

B
B

EKSPLORASI GINJAL
INDIKASI ABSOLUT
1. perdarahan ginjal yang
persisten hematoma meluas,
denyut, hematom
retroperitoneal
2. trauma renal derajat V

EKSPLORASI GINJAL
INDIKASI RELATIF
1. Trauma tumpul & tembus ginjal
komplikasi: ekstravasasi urin persisten,
abses perinefrik, urinoma terinfeksi, &
perdarahan
2. trauma derajat III & IV dg jar non-vital luas &
trauma organ intraperitoneal
3. trauma grade IV dg laserasi pelvis renalis,
parenkim ginjal & sistem kolektivus & avulsi
UPJ
4. trauma tumpul dg hematom retroperitoneal
& kelainan pd single shot IVP

Algoritma Pengelolaan Trauma Ginjal

(a)IVP pada trauma tumpul ginjal dengan trauma pada

pelvis renalis yang ditunjukkan ekstravasasi kontras
(b)Tomogram yang menunjukkan trauma ginjal
mengenai kaliks pole bawah

TRAUMA VASKULAR
Trauma vaskular renal (50%) syok (+)
mortalitas 10-50%
Trauma arteri renalis sulit utk diselamatkan
& rekonstruksi
Pembedahan rekonstruksi < 12 jam >>>
diselamatkan keberhasilan revaskularisasi
10-30%, fs ginjal
CT
Scan
ginjal
menunjukkan
absen
komplit
kontras
pada
ginjal kiri oleh karena
adanya avulsi komplit
pedikel renal

TROMBOSIS ARTERI RENALIS

NEFREKTOMI

CT Scan ginjal kiri dengan trombosis arteri renalis,

menunjukkan kurangnya perfusi kontras ke ginjal
(kiri); Arteriografi menunjukkan oklusi komplit
arteri renalis kiri sekunder akibat trombus
Pergerakan
ginjal
ok
deselerasi peregangan
arteri renalis ruptur
intima trombus

EKSPLORASI & REKONSTRUKSI GINJAL

Insisi midline transabdominal dr proc
xiphoideus - simfisis pubis
Kolon transversum rongga dada (bungkus
kasa lembab)
Identifikasi cab a. mesenterika pd usus halus
Angkat usus keatas dan ke kanan
retroperitoneum tampak
Insisi vertikal di atas aorta superior dr a.
mesenterika superior smp retroperitoneum
perluas keatas dr lig Treitz
V. mesenterika inf petunjuk insisi diseksi
hingga ant perm aorta
Diseksi smp sup hingga v. renalis sin tanda
identifikasi pd renalis tegel dipasang

EKSPLORASI & REKONSTRUKSI GINJAL

Kontrol PD (+) evakuasi hematom
retroperitoneal
Insisi fasia Gerota di lateral ginjal terpapar
evaluasi pelvis renalis, parenkim & pd
Rekonstruksi debridement adekuat: jar mati
dibuang preservasi kapsula renalis utk
penutupan ginjal
Ligasi PD parenkim kromik 4/0
Laserasi sistem kolektivus dijahit scr kedap air
(watertight fashion) kromik 4/0.
Inj metilen blue ke pelvis renalis identifikasi
trauma lain & penutupan sistem kolektivus
Tutup kapsula renalis reaproksimasi tepi
parenkim jahitan interrupted Vicryl 3/0
Jk defek ginjal luas packing dg agen
hemostasis (Avitene, Tissel, lemak perinefrik)

EKSPLORASI & REKONSTRUKSI GINJAL

Segmen pole ginjal tidak vital (+) parsial
nefrektomi (amputasi & penutupan sistem
kolektivus) pakai omentum utk tutup defek
pole ginjal jk kapsula renalis (-)
Pasang Penrose drain (drainase
retroperitoneum) Suction drain tidak boleh

EKSPLORASI & REKONSTRUKSI GINJAL

EKSPLORASI & REKONSTRUKSI GINJAL

EKSPLORASI & REKONSTRUKSI GINJAL

EKSPLORASI & REKONSTRUKSI GINJAL

EKSPLORASI & REKONSTRUKSI GINJAL

DAMAGE CONTROL
Coburn (2002): keuntungan
penyelamatan ginjal
packing dg laparotomy pads kontrol
perdrhn & dibuka kembali dalam 24 jam
eksplorasi & evaluasi luas trauma
mencegah nefrektomi total

NEFREKTOMI
Indikasi :

Trauma ginjal ekstensif, hemodinamik

tidak stabil, suhu tubuh rendah, &
koagulasi buruk renal repair tdk mgkn
(fs ginjal kontralateral N)
Nash dkk (1995) 77% nefrektomi (+)
ok perdrhn parenkim luas, vaskular &
kombinasi, 23% ok hemodinamik tdk
stabil dg ginjal dpt direkonstruksi.

Complication
Recommendations
Complication following renal trauma require a
thorough radiographic evaluation

Medical management and minimally invasive

technique should be the first choice for the
management of complications
Renal salvage should be the surgeons aim for
patients in whom surgical intervention is
necessary

GR

KOMPLIKASI
Ekstravasasi urin persisten urinoma,
infeksi perinefrik & kehilangan ginjal
Obs ketat & AB tepat
Perdarahan ginjal tertunda (21 hari)
bedrest, hidrasi, angiografi & embolisasi
hipertensi arterial

Post Operative Care and Follow-Up

Recommendations
Repeat imaging is recommended for all hospitalized
patients within 2-4 days of significant renal trauma
(although no specific data exists). Repeat imaging is
always recommended in cases of fever, flank pain, or
falling haematrocrit
Nuclear scintigraphy before discharge from the hospital is
useful for documenting functional recovery
Within 3 month of major renal injury, patients follow-up
should involve:
1. Physical examination
2. Urinalysis
3. Individualized radiological investigation
4. Serial blood pressure measurement
5. Serum determination of renal function
Long-term follow-up should be dedicated on a case-bycase basis but should at the very last involve
monitoring for renovascular hypertension

GR

Paediatric Renal Trauma

Recommendations
Indications for radiography evaluation of children
suspect of renal trauma include:
1. Blund and penetrating trauma patients with any
level of haematuria
2. Patient with associated abdominal injury regardless
of the findings of urinalysis
3. Patient with normal urinaluses who sustained a rapid
deceleration event, direct flank trauma, or all a fall
from a height
Ultrasonography is the considered a reliable method of
screening and monitoring blunt renal injuries by
some researchers, but is not universally accepted
CT scanning is the imaging study of choice for staging
renal injuries
Haemodynamic instability and a diagnoses grade 5
injury are absolute indications for surgical

GR

B
B
B

Renal Injury in The Polytrauma Patient

Recommendations
Polytrauma patients with associated renal injuries
should be evaluated on the basic of the most
threatening injury

GR
C

In case where surgical intervention is chosen, all

associated injuries be evaluated simultaneously

The decision for conservative management should

consider all injuries independently

Percutaneous Renal Procedures

Recommendations
Latrogenic rupture of the main renal artery should
be treated with balloon tamponade, and, in case
of failure, with a stent graft
Surgical venous injuries should be managed with
venorrhaphy or patch agioplasty
The transoanted kidney should be evaluated on
the basis of renal function, type of injury and the
patients conditions
Hyperselective embolisation may control arterial
bleeding during percutaneous procedures

GR
C

Algorithm for The Management of

Paediatric Renal Trauma
Paediatric renal trauma

Blunt

Penetrating

UA

UA

>50 rbc/hpf or
deceleration

UA

<50 rbc/hpf or
haemodynamically
stable

Stable

>5 rbc/hpf

Unstable

Unstable

CT Scan

Abdominal
exploration

Abdominal
exploration

CT Scan

Observes
Observes

Stable

Renal
exploration

IVP
NL

Observes

ABNL

Renal
exploration

Renal
exploration

IVP
NL

Observes

ABNL

Renal
exploration

Evaluation of Bunt Renal Trauma in Adults

Suspected adult blunt Renal trauma
Determine haemodynamic
stability
Stable

Unstable
Microscopic
haematueria

Gross haematueria

Renal Imaging

Rapid
deceleraton
Injury or Major
associated
injuries
Grade 1-2

Grade 3-4

Emergency
laparotomy
One-shot IVP

Observation

Normal IVP

Stable

Retroperitoneal
haematoma

Grade 5

Observation,
bed rest.
Serial Ht,
antibiotics

Associated
injuries
requiring
laparotomy

Renal
exploration

Pulsatile or
expanding
Abnormal
IVP

Evaluation of Penetrating Renal Trauma in Adults

Suspected adult blunt Renal trauma
Determine haemodynamic
stability

Stable

Unstable
Emergency
laparotomy
One-shot
IVP

Renal Imaging

Grade 3

Grade 4-5

Grade 1-2

Observation

Stable

Observation,
bed rest.
Serial Ht,
antibiotics

Associated
injuries
requiring
laparotomy

Normal IVP

Retroperitoneal
haematoma
Pulsatile or
expanding

Renal
exploration

Abnormal
IVP